Some people have felt that the program was moving too slowly, but it takes time to work out differences which have long existed.

But as we view it, the way we are proceeding gives the best possible foundation for the program, because it is stimulating local initiative all over the country.

Mr. KYROS. I am delighted to hear you say that, Dr. Lee. I know from my experience from talking with doctors in the State of Maine, that they think the program is an outstanding one, that it doesn't encroach on them, and I think this is a credit to your administration.

You are the people who have to do a hard job, and I want to commend you highly on administering a program like this, which is complicated-and particularly because of the important relationship between doctors and patients.

You have done an outstanding job, and I am proud of you.

Mr. ROGERS. Mr. Carter?

Mr. CARTER. I notice that the new bill will include an authorization for funds for treatment of alcoholics, and it will also include funds for treatment of addicts, too.

Dr. LEE. Yes, sir.

Mr. CARTER. How much will that be this year and next year, your additional authorization?

Dr. LEE. The amount that we have requested is, for the alcoholics, $7 million, and for the narcotic addict rehabilitation, $8 million, and in fiscal 1970, $15 million for the alcoholics and $10 million for the addicts.

Most of that money will be for the development of services rather than construction. It is about 30 percent for construction or renovation of facilities.

Mr. CARTER. Will these treatment centers for alcoholics and narcotic addicts be an integral part of the mental health centers, or will they be separate?

Dr. LEE. I would like to ask Dr. Yolles to further elaborate on that. Dr. YOLLES. These treatment facilities, Dr. Carter, would be built into the community health center and would be an integral part of it. We would even relate the special facilities for homeless alcoholics to this continuum of services. This is the key point in the legislation to relate these services for treatment of alcoholics and narcotic addicts to the total panoply of services in the community health center.

They may be physically separated, but there would be adequate transfer of patients and records between the services, just as in the basic program.

Mr. CARTER. I think that it is good that it is so. It will be less difficult, as I see it.

I notice that in your regional health development, 11 regions have been funded. Is that right?

Dr. LEE. Yes, 11 operational grants have been funded, and 53 planning grants.

Mr. CARTER. This is in its infancy at the present time?

Dr. LEE. That is correct, sir.

Mr. CARTER. Of course, there has been a decrease in the number of strokes in the past 3 years, but you really wouldn't attribute all that decrease to the establishment of these 11 regions?

Dr. LEE. No, not at all, Dr. Carter.

I think we would not want to imply that either these programs or some of the other programs that have been initiated in the last 3 years that have been making good progress would in any way have done so. They may have contributed, but certainly, as far as the national figure is concerned, it would be a slight contribution to date.

Mr. CARTER. Actually, there are improved methods of treatment, really, different medicines used in treatment of strokes that have been mainly responsible for this.

Dr. LEE. Yes, sir. I think the improved drugs and the earlier diagnosis of the hypertensive association that they get under treatment at an earlier stage of the disease have contributed to this.

Mr. CARTER. I would like to know how the specific organization of a region is. Could you give us a plan, who is head of it, and how it branches down?

Dr. MARSTON. I think what one needs, Dr. Carter, is the organization of more than one region to achieve what you want.

The one thing that has to be established in each region is a broadly representative regional advisory group. It is a requirement of the law that this be established.

In every region, so far as I can remember, there are task forces in the areas of heart disease, cancer, and stroke, which include people with special knowledge in these areas.

In each region there is also a core administrative unit, a staff that varies in size. But on the average in the regions funded for planning only, it is about 20 to 26 people, and in the operational regions, the staff that is actually paid on an average number about 90.

Operation of the program is set up differently in different regions. In Connecticut there are 10 subregions. In Kansas there are 10 subregions. In Georgia, there is really a subregion for each county, with representatives from every hospital in the State, and with representatives from every county medical society. These local-level groups are active in determining their local needs. In some instances these units are called local advisory groups.

Now, to come to a specific region, in Kansas these local action groups may either respond to information that has come from studies carried out by the regional staff or, indeed, other groups in the State. Or the local action groups may propose projects that they themselves identify as being particularly needed in that area. In designing these projects, the local action groups can work with the staff of the regional medical program, calling on experts from outside of the region, if necessary.

Kansas has a substantive review committee, that is, a committee that reviews, on the basis of scientific and professional merit, the proposals. Finally, with the results of this review available, the application, which may have been stimulated either at the local level or may have been stimulated as the result of data that has been gathered elsewhere, comes before the regional advisory group, which must approve all operational project proposals.

A recent example of this process in Kansas resulted in about half of the proposals that came to the regional advisory group being returned to the originators for one reason or another for additional work before final approval at the regional level. After regional ad

visory group approval is gained, a grant proposal for funding program activities comes to the Division of Regional Medical Programs. At this point, we have the opportunity to have special site visits as we did in the case of the Washington-Alaska Region's operational application. In this case we actually visited the locations where projects were proposed, and made a report to our review committee and, finally, to our National Advisory Council.

Does this help?

Mr. CARTER. Yes, sir; that is helpful.

What procedures do you have for continuing education to get to the general practitioner and communities your advances in research?

Dr. MARSTON. Again, this has varied. There have been some instances in which a community took the lead. Great Bend, Kans., for example, has established an educational subcenter, if you want, for the area immediately surrounding Great Bend.

The purpose here is to try to focus education and to focus care as close to the patient's home as possible. And in the instance of Kansas, you find this focus has been moved out away from the university to subcenters.

In other areas, preexisting programs and facilities have been utiized-Albany, N.Y., for example, has a two-way radio system which provides in-hospital education throughout much of the New England area. This has been augmented by the Albany regional medical program.

I would say continuing education related to the physician and the patient's needs, as opposed to continuing education that somehow has drifted away from the care of patients, is a very major focus of the program.

Mr. CARTER. Do you have regional seminars on newer concepts in medicine attended by practitioners from the subregions?

Dr. MARSTON. There was a major one in Oregon that a member of my staff attended not long ago.

Mr. CARTER. The purpose of this bill is to diminish deaths from heart disease, cancer, and stroke.

Do you have available to the practitioners in the subregions close liaison with specialists in the regional areas so that they can get information quickly, or advice, or help in treatment?

Dr. MARSTON. There is an example in Wisconsin of a 24-hour-a-day telephone service to physicians in the area. There is a specialty team in Iowa that has been activated to actually go out to the scene and provide consultation to the local physician and his stroke patients. Mr. CARTER. That is part of your regional system at the present time?

Dr. MARSTON. Yes.

Mr. CARTER. I want to congratulate you on that. I think that is very good. I certainly feel that these ideas, or these questions which I have asked you should be further implemented, if possible.

Thank you, Mr. Chairman.

Mr. ROGERS. Mr. Skubitz?

Mr. SKUBITZ. Thank you, Mr. Chairman.

Doctor, I am a new member on this committee, and I am from the great State of Kansas that you have been praising so highly. Doctor, I am interested in a number of things.

First, I want to say I appreciate the fact that you are interested in Kansas. I hope we can get some money to keep this show on the road.

How much money was authorized, Doctor, for these regional medical programs in 1966?

Dr. MARSTON. The authorization was $50 million.

Mr. SKUBITZ. How much was appropriated?

Dr. MARSTON. $25 million, including $24 million for grants-$25 million total.

Mr. SKUBITZ. In 1967, how much was authorized?

Dr. MARSTON. The authorization was $90 million. The appropriation was $43 million for grants and $2 million for direct operations. Mr. SKUBITZ. You have a total of how much?

Dr. MARSTON. $45 million was appropriated for 1967, $25 million appropriated for 1966, so that would be a total of $70 million.

Mr. SKUBITZ. In 1968, how much was authorized?

Dr. MARSTON. $200 million. We have received $53.9 million in appropriations for grants and $4,900,000 for direct operations, for a total of $58.8 million.

Mr. SKUBITZ. Out of this total amount of appropriations, how much do you have available to you now?

Dr. MARSTON. $53.8 million—including $4.9 million for direct operations. This total is comprised of $27.9 million of our 1968 appropriation $30.9 million was put in reserve-plus $25.9 million in carryover funds.

Mr. SKUBITZ. The thing that bothers me, Doctor, is that you come here with an excellent program. It looks fine on paper. But, unless this Congress gives you money we accomplish nothing. So far as I am concerned, I want to be as helpful as I can to assist you in this important work.

Thank you, Mr. Chairman.

Dr. LEE. I would like to make an additional comment on that, Mr. Chairman.

As the program has developed, of course, with the evolution of the planning, the authorizations were well above those required, and as we move into the operational phase, we feel that, of course, significantly more funds will be required with the operating programs. Planning is one thing, but operating programs is quite another. Mr. CARTER. Mr. Chairman, would the gentleman yield?

Just how has this money been spent, Doctor, most of it?

Dr. LEE. The money, primarily, goes, of course, for the hiring of staff and for the activities of the staff, in some cases for the purchase of equipment, the development of coronary care unit, or for longdistance transmission of cardiograms, which is being tested on an experimental basis.

This kind of thing, staff and equipment, which would be related to the educational efforts—

Mr. CARTER. Do you have a central place in each region, to which place cardiograms may be transmitted by phone?

Dr. LEE. Not in each region. I think that the experimental program is going on in Missouri.

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Dr. MARSTON. That is a major one, which has been supported by the National Center for Chronic Disease Control over the last 5 years. It is being field tested in Missouri at the present.

Mr. CARTER. In one region you have such

Dr. MARSTON. Yes.

Mr. CARTER. Do you envision in the future the use of such centralized diagnostic aids?

Dr. LEE. If we find the experiment in Missouri is successful, and it is demonstrated that you can improve patient care, and that it is feasible from a cost standpoint, that other regions will then want to develop similar programs. It may be that a computer would serve perhaps more than one region. These are expensive, depending on the kinds of programs that are developed, such as automated multiphasic screening.

Mr. SKUBITZ. For example, to detect some of the diseases early, cancer and cardiovascular diseases particularly, the development of the automated long-distance cardiograms-as other advances take place, say, in the area of radiology, it may be that those would also be applied on a regional basis.

I think it is wise to test them out first in a single area, as is now being done in Missouri, to find out how feasible it is at the level of the community hospital, and in the communities where the patients are and the physicians are in practice, to see if it is practical.

Mr. CARTER. Many of our community hospitals have lines to these places to interpret their cardiograms in that way.

Dr. MARSTON. Dr. Carter, this goes a bit beyond that. The reason they wanted to try this advanced system is that, in addition to the usual telephone lines for the transmission of EKG, this new system doesn't take the place of interpretation by the physician, but does save time in supplying the attending physician with an analysis of the electrocardiogram done by a centrally situated computer.

What this project is facing is the fact that we are not going to have enough trained manpower over time to do EKG analyses, and we have to develop some system to augment the highly skilled manpower required in this area. So this system is more than a telephone line. Mr. SKUBITZ. Mr. Chairman, may I ask one more question? Mr. ROGERS. Yes.

Mr. SKUBITZ. Did you say $200 million was authorized in 1968? Dr. MARSTON. Yes, sir.

Mr. SKUBITZ. How much did Congress appropriate?

Dr. MARSTON. $53,900,000 for grants, and $4,914,000 for direct operations.

Mr. SKUBITZ. Thank you.

Mr. ROGERS. What do you think of combining the comprehensive health planning program and the regional program? What would you think of combining these two programs?

Dr. LEE. The two programs have a different purpose. As we move down the path and as these programs develop, they will be obviously closely coordinated and integrated. But I don't believe they should be combined into a single program.

Mr. ROGERS. You don't feel that a comprehensive health plan for a State should include what we are doing in this regional program?